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Simulation for Student Learning –Electronic Health Records

As hospital electronic documenta-tion systems continuously evolve,clinical nurses struggle to keep

pace with increasingly new medicalequipment and technologies to captureappropriate data for the electronic healthrecord (EHR), and their education needsare constant. With the AmericanRecovery and Rein vestment Act of 2009,President Obama signed into law the pol-icy incentives to advance hospital acqui-sition of health information technologysystems. This proliferation of new tech-nologies has forced nursing education toadd new documentation skills to the cur-riculum in anticipation of student nursesworking in these technology-driven hos-pital systems. In the Institute ofMedicine’s (IOM) (2010) report, nurse edu-cators are called upon to supplement cur-riculum and integrate technologies.Through coursework, clinical experi-ences, and simulation exercises, nursingstudents are expected to work with elec-tronic health information so they are ade-quately prepared for the working world.

A particular need is to understand thefundamentals of charting using an elec-tronic health record (EHR) (Rubbelke,Keenan, & Haycraft, 2014) and the bene-fits of learning a standardized nursing ter-minology so the “elements” of nursingcan be part of that electronic record andare fundamental. Using a standardizedterminology such as the Clinical CareClassification (CCC) System is critical tocapture nursing actions in the hospital-wide systems today (Englebright, Aldrich,& Taylor, 2014).

The pedagogy associated with simu-lation is based on the importance ofdebriefing (Zigmont, Kappus, & Sudikoff,2011). The process of debriefing is the crit-ical final step for students to internalizethe simulated experience and reflect ontheir observed performance with feed-back on their cognitive choices in theencounter with a simulated patient. Thisprovides a good opportunity to use theapplication of documenting nursing carein the teacher-student interaction aboutthe simulated patient-student experience.Using a nursing documentation systemwith a coded, standardized terminology

can structure the communication andexchange in debriefing. This has addedvalue to the student who is learning thefull encounter from assessment throughdocumentation, especially applying thenursing terminology at an importantpoint when learning is maximized.

Simulation and the PC-CCC –Emerging Technologies Grant

The purpose of the “EmergingTechnologies” grant program was toidentify innovative technologies thatenhance the learning experience for stu-dents at Molloy. The program supported

Teaching Electronic Charting with Simulation And Debriefing in Early Fundamentals

Jennifer E. ManninoGeraldine Cornell

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Jennifer E. Mannino, MS, MA, RN, is anAssistant Professor of Nursing at Molloy College,Rockville Centre, NY; a current Faculty ofUndergraduate Nursing Students; and a memberon the Emerging Technologies Committee.

Geraldine Cornell, MS, RN, is an AssistantProfessor of Nursing, Molloy College, RockvilleCentre, NY, a current Course Coordinator,Foundations of Humanistic Nursing PracticeCourse; and a past Co-Chair of the SimulationTask Force.

This project was implemented with support from the “EmergingTechnologies” grant program at Molloy College. The authors pur-chased two workstations-on-wheels (WOWs), three Lenovo® tablets,and two printers to be set up in the simulation labs. The software (PC-CCC) was downloaded free from www.sabacare.com, and the instruc-tions were developed with online software to capture lectures(Blueberry Standard) and were distributed to students prior to and inconjunction with the activities. The students did the simulations as partof their fundamentals experience in the lab with high fidelity simula-tors, a “patient” actor, and the computer workstation next to the bed.Jennifer E Mannino Geraldine Cornell

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faculty to use technologies in teaching.The evidence-based Microsoft Access®

PC-CCC, developed by Feeg, Saba, andFeeg (2008), is a field-tested documenta-tion system that we incorporated into thesimulation lab experience of students inthe fundamentals course in our program.The PC-CCC uses the terminology devel-oped by Virginia Saba and colleaguesusing an automated, drop-down menuapproach to documenting nursing care(sabacare.com). The software is a free,downloadable application from theInternet that can be used in conjunctionwith the fundamentals required by stu-dents learning early patient care docu-mentation related to planning care. Ourgoal in the “Emerging Technologies”grant was to go beyond the EHR experi-ence for students. While the main goal ofthe system is to teach electronic docu-mentation, the process of students docu-menting their understanding of caredelivered and coded language could pro-vide an additional learning outcomewhen used with debriefing in simulation.With this combination, learning could gobeyond the process of documentation,and the simulated experience could pro-vide a full student-patient encounter,concluding with appropriate electroniccharting that becomes part of the simu-lated patient’s plan of care.

Following earlier preparation proce-dures reported in the literature (Feeg etal., 2008; Mannino & Feeg 2011, 2012),students were emailed a short PC-CCCvideo introduction and step-by-step tuto-rial, along with two simulated patient sce-narios prior to their simulation experience(http://sabacare.com/ToolKit/DesktopDemo.html). They were instructed toview the videos, review the nursingprocess, and consider potential nursingplans of care for the two simulatedpatient scenarios. On the morning of thesimulation experience, paired studentspracticed documentation on LenovoThink Pad© tablets equipped with PC-CCC software. As students entered thesimulation lab one pair at a time, theyreceived verbal report by faculty on oneof the two patients they were previouslyassigned. The students then had 15 min-utes to introduce themselves to thepatient, perform a focused patient assess-ment, prioritize, and provide patient carefollowed by documentation of their planof care using the PC-CCC software.

Design and MethodThe PC-CCC is designed according to

the nursing process. Using the PC-CCC in

nursing education not only provides stu-dents with the psychomotor experienceof electronic documentation, but aids intheir understanding and use of the nurs-ing process. Figure 1 demonstrates howthe PC-CCC guides users through thesteps of the nursing process. Usingassessment techniques, the student firstidentifies a care category and care com-ponent. Next, a nursing diagnosis withsupporting free-text data is entered toidentify an actual or a potential patienthealth concern. Each plan of care createdusing the PC-CCC then requires the docu-mentation of an expected patient out-come with nursing actions and specificnursing interventions necessary toachieve that expected outcome. Manyplans of care can be active at one time,and each is identified with an individualproblem identification number. Althoughnot used in this simulation experience,once interventions are carried out, anyplan of care in the database may beevaluated for success, and an actual out-come may be documented. Integrationof the PCCC with simulation exercisesprovides an excellent critical thinkingexercise that not only allows for electron-ic documentation, but fosters the nursingstudent’s cognitive growth by linkingpatient outcomes to nursing actions(Mannino & Feeg, 2012).

In this project, 77 second-year stu-dent nurses were introduced to a simula-

tion environment with technology. In thebrief 15-minute scenario, students wereable to assess patients, prioritize, providecare, and document a plan of care usingthe PC-CCC patient care record uploadedonto a work station on wheels (WOW).During the simulation scenario, studentsdemonstrated effective communicationand worked together as a collaborativeteam exchanging information aboutpatient assessments, nursing diagnosisand interventions.

DebriefingThe period following the simulation

experience, often referred to as debrief-ing or “post-simulation” experience, is anintegral part of learning in nursing edu-cation (Johnson-Russell & Baily, 2010;National League for Nursing SimulationInnovation Resource Center [NLN-SIRC],2010). According to the InternationalNursing Association for Clinical Simu -lation and Learning (INACSL) standardsof best practice in simulation, debriefingis to “move toward assimilation andaccommodation in order to transferlearning to future situations” (INACSL,2011, p. 53). Debriefing improves criticalthinking, clinical judgment, and clinicalperformance in students (Driefuerst,2009; Wickers, 2010). Further, debriefingprovides an opportunity for reflectivelearning and identification of mentalmodels that lead to behaviors or cogni-

Figure 1.Screen Shot of Main User Interface

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tive processes that provide the ability tobuild new mental models to be used infuture experiences (Zigmont et al., 2011).

Debriefing Using the PC-CCCA structured framework is required

to promote learning in the debriefingperiod. A critical component needed forthe simulation and debriefing experienceis the establishment of defined learningobjectives with projected outcomes forstudents. Defined learning objectivesprovide structure for evaluating the sim-ulation experience. Additionally, debrief-ing after simulation requires severalessential components. Attributes such asreflection, emotion, reception, integra-tion, and assimilation can frame simula-tion debriefing. Integration and assimila-tion can be achieved when the facilitatormodels framing and embeds the experi-ences of the simulation into scaffoldingthat are familiar to the learner. Thisallows the learner to reference when infuture care situations (Driefuerst, 2009).

A suggested framework for debrief-ing in nursing education is to follow astructure similar to the nursing process.“Integrating elements of the nursingprocess in debriefing sets the stage forassimilation of the knowledge, skills andattitudes into practice and provides apath for accommodation and transfer-ence into future patient care environ-ments” (Driefuerst, 2009, p. 111). Usingthis structure, appropriate nursing inter-ventions and thought processes leadingto the prioritization of actions may be

revealed. The use of the PC-CCCIndividual Care Record (see Figure 2) hasprovided a framework for student nurseswithin the simulation experience andthroughout the debriefing process.

The PC-CCC Individual Care Recordwas used in the debriefing period as aguide for faculty as well. Documentationon the patient care record enabled thefacilitator to guide student reflectionrelated to their individual simulationexperiences. Nursing process, nursingdiagnosis, goals, and interventions werediscussed with students. Through the useof the PC-CCC, several priority nursingdiagnosis goals and interventions wereappropriately documented.

The care records were used by thefaculty to enable students to reflect uponhow they came to priority decisions andconclusions about each patient. Usingthe PC-CCC Individual Care Record addi-tionally provided students with the abili-ty to review the thought processes anddecision-making of other studentsregarding a different priority nursingdiagnosis with goals and interventions.For novice student nurses, the use of thePC-CCC Individual Care Record withinsimulation provided student nurses withmultiple opportunities for successfullearning.

Evaluations of the PC-CCCEvaluations were carried out using

the same 13-item PC-CCC usability sur-vey previously used by Mannino andFeeg (2010). Students (n = 77) reported at

least an 87% agreement with all items.Items with greater than ninety percentagreement included statements such as:1) This program aided my ability to under-stand and prioritize nursing diagnosis; 2)This program aided my ability to understandand prioritize nursing interventions, 3) Usingthis program aided my ability to understandnursing care plans; 4) Using this programaided my ability to create nursing care plans;5) I would like to continue using this pro-gram for all nursing courses that require thedevelopment of nursing care plans; 6) Thescreen design was organized and clear; 7)The format was easy to follow; 8) The infor-mation was easy to understand; 9) The sys-tem allowed me to chart my care plan; 10)The system was efficient to enter the data;and 11) I would recommend using this pro-gram at the bedside. Overall students’were pleased with the PC-CCC andresponses were very positive. Facultyagrees the PC-CCC program enhancesthe simulation experience and positivelyaffects student learning.

Learning Beyond Documentation AloneAdditional learning objectives for

the simulation experience and debriefingin this project were developed based onthe IOM (2010) recommendations totransform nursing education and inte-grate technologies. Competencies devel-oped from the Quality and SafetyEducation for Nurses (QSEN) project wasused to guide nurse educators towardthe creation and implementation of sim-ulation scenarios using the PC-CCC. TheQSEN competency for Informatics focus-es on the change of Knowledge, Skills,and Attitudes (KSAs) through the use of“information and technology to commu-nicate, manage knowledge, mitigateerror, and support decision making”(Cronenwett et al., 2007, p. 129).

Through the simulation experiencewith the use of the PC-CCC and faculty-guided debriefing, fundamental studentlearners were able to demonstrate with-in the KSA competency recommenda-tions for Informatics. Learners were ableto describe examples of how technologyand information management are relat-ed to the quality and safety of patientcare, as well as recognize the time, effort,and skill required for computers, data-bases, and other technologies to becomereliable and effective tools for patientcare. Additionally, student learners hadthe opportunity to demonstrate skills byusing the WOW and the PC-CCC to doc-ument and plan patient care in an elec-tronic health record. Attitudes that were

Note: Patient information is based on a simulation exercise and does not reflect actual patientdata.

Figure 2.PC-CCC Individual Care Record

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modeled by nurse faculty in this projectemphasized the value of technologiesthat support clinical decision-making,error prevention, and care coordination,as well as the importance of nurses’involvement in design, selection, imple-mentation, and evaluation of informa-tion technologies to support patient care.

ConclusionSimulation in nursing education pro-

vides an experiential and learner-cen-tered experience for learners. Even earlyin their program, through immersion andhands-on activities, learners can assumean active role in patient care while prac-ticing in a safe setting. Simulation offersthe opportunity to bridge the gapbetween theory and practice by allowingstudents to apply knowledge and clinicalreasoning skills to actual patient care sit-uations (Durham & Alden, 2012). Theaddition of the simulated electronic doc-umentation component gave the stu-dents a full 360-degree patient-careexperience from taking report to chart-ing on the computer. DN

ReferencesAmerican Recovery and Reinvestment Act of 2009,

111d. Cong. 1. Retrieved from http://www.gpo.gov/fdsys/pkg/BILLS-111hr1enr/pdf/BILLS-111hr1enr.pdf

Cronenwett, L., Sherwood, G., Barnsteiner, J.,Disch, J., Johnson, J., Mitchell, P., … Warren,J. (2007). Quality and safety education fornurses. Nursing Outlook, 55(3), 122-131.

Dreifuerst, K.T. (2009). The essentials of debriefingin simulation learning: A concept analysis.Nursing Education Perspectives, 30(2), 109-114.

Durham, C.F., & Alden, K.R. (2012). Integratingquality and safety competencies in simulation.Quality and safety in nursing: A competencyapproach to improving outcomes. Ames, IA:John Wiley & Sons, Inc.

Englebright, J., Aldrich, K., & Taylor, C. (2014).Defining and incorporating basic nursingactions into the electronic health record.Journal of Nursing Scholarship, 46(1), 50-57.

Feeg, V., Saba, V., & Feeg, A. (2008). Testing a bed-side personal computer clinical care classifica-tion system for nursing students usingMicrosoft access. CIN: Computers, Infor -matics, Nursing, 26(6), 339-349.

International Nursing Association for ClinicalSimulation and Learning (INACSL). (2011).Standard I: terminology. Clinical Simulation inNursing, 7, s3-s7.

Institute of Medicine (IOM). (2010). The future ofnursing: Focus on education Retrieved fromhttp://www.iom.edu/Reports/2010/The-Future-of-Nursing-Leading-Change-Advancing-Health/Report-Brief-Education.aspx

Johnson-Russell, J., & Baily, C. (2010). Facilitateddebriefing. In W.M. Nehring, & F.R. Lashley(Eds.), High-fidelity patient simulation in nurs-ing education (pp. 369-385). Boston: Jonesand Bartlett.

Mannino, J., & Feeg, V. (2011). Field-testing a PCelectronic documentation system using theClinical Care Classification© System withnursing students. Journal of HealthcareEngineering, 2(2), 223-224.

Mannino, J., & Feeg, V. (2012). Nursing educationapplication of the Sabacare Clinical CareClassification (CCC) using the personal com-puter (PC). In V.K. Saba (Ed.), Clinical CareClassification (CCC) System: User’s guide –Version 2.5 (2nd ed.). New York, NY: SpringerPublishing.

National League for Nursing Simulation InnovationResource Center (NLN-SIRC). (2010). SIRCglossary. Retrieved June 15, 2014 fromhttp://sirc.nln.org/mod/glossary/view.php?id=183

Rubbelke, C., Keenan, S., Haycraft, L. (2014). Aninteractive simulatged electronic health recordusing Google Drive. CIN: Computers,Informatics, Nursing, 32(1), 1-6.

Wickers, P.M. (2010). Establishing the climate for asuccessful debriefing. Clinical Simulation inNursing, 6, e83-e86.

Zigmont, J., Kappus, L., & Sudikoff, S. (2011). The3D model of debriefing: Defusing, discovering,and deepening. Seminars in Perinatology, 38,52-58.

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